Provider Demographics
NPI:1568928885
Name:VITALE, VINCENT PATRICK (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:PATRICK
Last Name:VITALE
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5229
Mailing Address - Country:US
Mailing Address - Phone:516-625-1014
Mailing Address - Fax:516-414-4012
Practice Address - Street 1:400 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3417
Practice Address - Country:US
Practice Address - Phone:516-625-1014
Practice Address - Fax:516-414-4011
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty